Gastroenterology Today Summer 2022

Gastroenterology Today Summer 2022

Gastroenterology Today Summer 2022


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Volume 32 No. 2<br />

<strong>Summer</strong> <strong>2022</strong><br />

In this issue<br />

Xxx<br />

Xxx<br />

Xxx<br />

Anyone for<br />

Mobile Endoscopy?<br />

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6 FEATURE Gluten-free diet offers an effective option for<br />

those with IBS to manage their symptoms<br />

9 FEATURE Magnifying endoscopic findings of early-stage<br />

poorly differentiated colorectal adenocarcinoma:<br />

a case report<br />

Matthew’s Perspective:<br />

15 FEATURE Postpolypectomy fever in patients with serious<br />

infection: a report of two cases<br />

21 NEWS<br />

28 REPORT The Cost of Opioid-induced constipation (OIC)<br />

An essential report into the financial and personal<br />

cost of OIC<br />


This issue edited by:<br />

Hesam Ahmadi Nooredinvand<br />

c/o Media Publishing Company<br />

Greenoaks<br />

Lockhill<br />

Upper Sapey, Worcester, WR6 6XR<br />

What approach has 18 Week Support<br />

taken with regards to building an<br />

expert insourcing team?<br />


Media Publishing Company<br />

Greenoaks, Lockhill<br />

Upper Sapey, Worcester, WR6 6XR<br />

Tel: 01886 853715<br />

E: info@mediapublishingcompany.com<br />

Dr Matthew Banks is the Clinical Director for 18 Week Support <strong>Gastroenterology</strong>. He believes it starts with recruiting the<br />

www.MediaPublishingCompany.com<br />

best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit clinicians whose JAG performance data is well<br />

above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data<br />

is an excellent quality indicator, we now want to go a step beyond that and PUBLISHING monitor the Non-Technical DATES: skills (NTS) of each<br />

clinician as well. We now know that NTS plays an important role in safe and effective team performance. Therefore, in our<br />

March, June, September and December.<br />

quest to develop excellent teams who deliver a world-class service, we must focus on NTS’.<br />

Tammy and Lisa’s Perspective:<br />


Tammy Kingstree is Lead Nurse for Endoscopy.<br />

Media Publishing Company<br />

‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from<br />

Greenoaks<br />

our senior nurse coordinators who are trained to manage the patient pathway, manage a team of staff they may not know<br />

and to deal effectively with any issues which may arise on the day’. Lockhill<br />

Upper Sapey, Worcester, WR6 6XR<br />

Lisa Phillips is Lead Nurse for Endoscopy.<br />

‘The team objectives are clear. Excellent patient experience and good patient outcomes. Because the objectives are clear,<br />

team cohesion and focus are exceptionally good. It therefore shouldn’t matter PUBLISHERS that we are in an unfamiliar STATEMENT:<br />

endoscopy unit,<br />

the service should be seamless. If it isn’t, we do not stop until we get it right. The views and opinions expressed in<br />

this issue are not necessarily those of<br />

If you have an excellent NHS record and want to help clear NHS waiting list backlogs, reduce RTT waiting times and provide<br />

the Publisher, the Editors or Media<br />

high-quality patient care, get in touch by calling on 020 3892 6162 or email Gastro.Recruitment@18weeksupport.com<br />

Publishing Company.<br />


In this edition, Dr Matthew Banks, Clinical Lead for <strong>Gastroenterology</strong> at<br />

18 Week Support, explores what it is like to deliver endoscopy as part of<br />

a team in a modular endoscopy suite. These mobile units are increasingly<br />

popular for Trusts looking to secure extra theatre capacity quickly and cost<br />

effectively. With diagnostic waiting times still at record highs, it is likely that<br />

many of you will at some point work in such units, and Matthew’s experience<br />

and insights will hopefully prove helpful.<br />

Next Issue Autumn <strong>2022</strong><br />

Subscription Information – <strong>Summer</strong> <strong>2022</strong><br />

<strong>Gastroenterology</strong> <strong>Today</strong> is a quarterly<br />

publication currently sent free of charge to<br />

all senior qualified Gastroenterologists in<br />

the United Kingdom. It is also available<br />

by subscription to other interested individuals<br />

and institutions.<br />

UK:<br />

Individuals - £24.00 incl postage<br />

Commercial Organistations - £48.00 incl postage<br />

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Designed in the UK by me&you creative<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />




“A recent large<br />

multicenter<br />

study by the<br />

Sheffield<br />

<strong>Gastroenterology</strong><br />

group found<br />

that gluten free<br />

diet has similar<br />

efficacy to a<br />

low FODMAP<br />

diet which can<br />

perhaps provide<br />

a simpler and<br />

less restrictive<br />

dietary option in<br />

some patients<br />

with IBS.”<br />

Irritable bowel syndrome is a prevalent functional gastrointestinal disorder accounting<br />

for approximately a quarter of gastroenterologists’ time in the outpatient clinic. We know<br />

that diet plays a crucial role in management of these patients however choosing the right<br />

diet can be challenging.<br />

One of the most commonly used diets is the low FODMAP diet and although there is<br />

evidence to suggest many patients with IBS benefit from this, it is quite a restrictive diet<br />

meaning adherence can be an issue. A recent large multicenter study by the Sheffield<br />

<strong>Gastroenterology</strong> group found that gluten free diet has similar efficacy to a low FODMAP<br />

diet which can perhaps provide a simpler and less restrictive dietary option in some<br />

patients with IBS. We have an article summarising these findings in this summer issue of<br />

<strong>Gastroenterology</strong> <strong>Today</strong>. Other articles include:<br />

• Case report highlighting the importance of careful lesion assessment through use of<br />

magnification and chromoendoscopy to predict histology and hence appropriateness of<br />

endoscopic resection of a lesion found during endoscopic examination<br />

• Two cases of post-polypectomy fever, a rare but potentially serious condition with lifethreatening<br />

complications, highlighting the importance of early recognition and prompt<br />

antibiotic therapy<br />

Hesam Ahmadi Nooredinvand,<br />

St George’s Hospital<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />


Prescribe Entocort ® CR by brand<br />

instead of prednisolone<br />

• Rapid induction of remission from 2 weeks with<br />

Entocort ® CR* 1<br />

• ~50% fewer corticosteroid-associated side effects<br />

than prednisolone 2,3<br />

• Unlike Entocort ® CR, prednisolone increases<br />

susceptibility to, and severity of, infections †2,4<br />

• Entocort ® CR is the only controlled-release<br />

oral budesonide indicated for Crohn’s disease 2<br />

Help keep your Crohn’s patients out of hospital...<br />

...and where they want to be<br />

*Remission was defined as a score of ≤150 on the Crohn’s disease activity index.<br />

†Entocort ® CR should be used with caution in patients with infections where the use of glucocorticosteroids may have unwanted effects. 2<br />

ENTOCORT CR 3mg Capsules (budesonide) - Prescribing<br />

Information<br />

Please consult the Summary of Product Characteristics (SmPC) for full<br />

prescribing Information<br />

Presentation: Hard gelatin capsules for oral administration with an<br />

opaque, light grey body and an opaque, pink cap marked CIR 3mg in black<br />

radial print. Contains 3mg budesonide. Indications: Induction of remission<br />

in patients with mild to moderate Crohn’s disease affecting the ileum and/or<br />

the ascending colon. Induction of remission in patients with active<br />

microscopic colitis. Maintenance of remission in patients with microscopic<br />

colitis. Dosage and administration: Active Crohn’s disease (Adults): 9mg<br />

once daily in the morning for up to eight weeks. Full effect achieved in 2-4<br />

weeks. When treatment is to be discontinued, dose should normally be<br />

reduced in final 2-4 weeks. Active microscopic colitis (Adults): 9mg once<br />

daily in the morning. Maintenance of microscopic colitis (Adults): 6mg once<br />

daily in the morning, or the lowest effective dose. Paediatric population: Not<br />

recommended. Older people: No special dose adjustment recommended.<br />

Swallow whole with water. Do not chew. Contraindications:<br />

Hypersensitivity to the active substance or any of the excipients. Warnings<br />

and Precautions: Side effects typical of corticosteroids may occur. Visual<br />

disturbances may occur. If a patient presents with symptoms such as<br />

blurred vision or other visual disturbances they should be considered for<br />

referral to an ophthalmologist for evaluation of the possible causes.<br />

Systemic effects may include glaucoma and when prescribed at high doses<br />

for prolonged periods, Cushing’s syndrome, adrenal suppression, growth<br />

retardation, decreased bone mineral density and cataract. Caution in<br />

patients with infection, hypertension, diabetes mellitus, osteoporosis,<br />

peptic ulcer, glaucoma or cataracts or with a family history of diabetes or<br />

glaucoma. Particular care in patients with existing or previous history of<br />

severe affective disorders in them or their first degree relatives. Caution<br />

when transferring from glucocorticoid of high systemic effect to Entocort<br />

CR. Chicken pox and measles may have a more serious course in patients<br />

on oral steroids. They may also suppress the HPA axis and reduce the stress<br />

response. Reduced liver function may increase systemic exposure. When<br />

treatment is discontinued, reduce dose over last 2-4 weeks. Concomitant<br />

use of CYP3A inhibitors, such as ketoconazole and cobicistat-containing<br />

products, is expected to increase the risk of systemic side effects and<br />

should be avoided unless the benefits outweigh the risks. Excessive<br />

grapefruit juice may increase systemic exposure and should be avoided.<br />

Patients with fructose intolerance, glucose-galactose malabsorption or<br />

sucrose-isomaltase insufficiency should not take Entocort CR. Monitor<br />

height of children who use prolonged glucocorticoid therapy for risk of<br />

growth suppression. Interactions: Concomitant colestyramine may<br />

reduce Entocort CR uptake. Concomitant oestrogen and contraceptive<br />

steroids may increase effects. CYP3A4 inhibitors may increase systemic<br />

exposure. CYP3A4 inducers may reduce systemic exposure. May cause low<br />

values in ACTH stimulation test. Fertility, pregnancy and lactation: Only<br />

to be used during pregnancy when the potential benefits to the mother<br />

outweigh the risks for the foetus. May be used during breast feeding.<br />

Adverse reactions: Common: Cushingoid features, hypokalaemia,<br />

behavioural changes such as nervousness, insomnia, mood swings and<br />

depression, palpitations, dyspepsia, skin reactions (urticaria, exanthema),<br />

muscle cramps, menstrual disorders. Uncommon: anxiety, tremor,<br />

psychomotor hyperactivity. Rare: aggression, glaucoma, cataract, blurred<br />

vision, ecchymosis. Very rare: Anaphylactic reaction, growth retardation.<br />

Prescribers should consult the summary of product characteristics in<br />

relation to other adverse reactions. Marketing Authorisation Numbers,<br />

Package Quantities and basic NHS price: PL 36633/0006. Packs of 50<br />

capsules: £37.53. Packs of 100 capsules: £75.05. Legal category: POM.<br />

Marketing Authorisation Holder: Tillotts Pharma UK Ltd, The Stables,<br />

Wellingore Hall, Wellingore, Lincoln, LN5 0HX. Date of preparation of PI:<br />

February 2020<br />

Adverse events should be reported.<br />

Reporting forms and information can be<br />

found at https://yellowcard.mhra.gov.uk.<br />

Adverse events should also be reported to<br />

Tillotts Pharma UK Ltd. Tel: 01522 813500.<br />

References: 1. Campieri M et al. Gut 1997; 41: 209–214. 2. Entocort ®<br />

CR 3 mg capsules – Summary of Product Characteristics. 3. Rutgeerts<br />

P et al. N Engl J Med 1994; 331: 842–845. 4. Prednisolone 5 mg tablets<br />

– Summary of Product Characteristics.<br />

Date of preparation: August 2021. PU-00572.





New research from the Sheffield <strong>Gastroenterology</strong> group has<br />

found that a gluten-free diet offers an equally effective dietary<br />

treatment option for those with irritable bowel syndrome (IBS)<br />

looking to manage their symptoms, alongside first and secondline<br />

dietary advice currently recommended.<br />

In the largest multicentre study of its kind, researchers investigated the<br />

long-term use of the low-FODMAP diet, the recommended second-line<br />

dietary treatment option, amongst IBS patients originally advised on the<br />

diet by dietitians based in 5 key UK hospitals 1 . The study found that the<br />

low FODMAP diet had longevity and continued success for the majority<br />

of patients with 76% continuing to follow a personalised form of the diet<br />

up to 8 years later.<br />

A key insight from the study was that 68% of these patients who<br />

reported to be following a personalised low FODMAP diet in the long<br />

term, regularly purchased specialist gluten and wheat-free products to<br />

help manage their symptoms. This led researchers to question whether<br />

the gluten-free diet may in fact be a simpler route to the same benefit<br />

and whether the gluten-free diet is in fact the crux of the ‘personalised’<br />

low FODMAP diet, which has the potential to benefit a large percentage<br />

of IBS sufferers. This ‘FODMAP light’ or ‘FODMAP gentle’ approach<br />

could provide an alternative ‘bottom up’ management approach for IBS<br />

alongside the existing ‘top down’ low FODMAP diet (see fig. 1).<br />

IBS (see fig. 2). Whilst traditional advice was found to be more patient<br />

friendly, and so should remain the first-line dietary treatment option, the<br />

low FODMAP diet and gluten-free diet should be considered as equally<br />

effective second-line alternatives, based on patient preference and<br />

specialist opinion. These findings are of particular relevance, given that<br />

an earlier piece of research from the same team demonstrated inequity<br />

in GI dietetic service provision across England, with regional differences<br />

in the level of provision and extent of specialist care and insufficient time<br />

for clinic appointments 3 . Given these findings, there is an urgent need to<br />

consider less complex dietary interventions for common conditions such<br />

as IBS in order to maximise efficiency and standards in patient care.<br />

Dr Imran Aziz, Consultant<br />

Gastroenterologist at the Royal<br />

Hallamshire Hospital, Sheffield<br />

commented:<br />

“Diet appears to play a pivotal<br />

role in symptom generation in IBS<br />

patients. Over the last decade<br />

there has been a substantial<br />

increase in interest in the role of<br />

dietary therapies in IBS, including<br />

a gluten-free diet. This latest<br />

research shows that a glutenfree<br />

has a similar level of efficacy<br />

Fig. 2<br />

to traditional dietary and low<br />

FODMAP dietary advice and so deserves a seat at the table. It is an<br />

important step in providing IBS patients with choice, helping them to find<br />

relief from their symptoms in the simplest, most effective way for them.”<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

Fig. 1<br />

A follow-up randomised trial, led by the Sheffield team involved a headto-head<br />

investigation looking at the best treatment options for patients<br />

with IBS in real world conditions 2 . It compared traditional (first-line)<br />

dietary advice, a low FODMAP diet and a gluten-free diet.<br />

The key finding from the study was that all three diets were equally<br />

effective in managing symptoms for patients with non-constipated<br />

Katie Kennedy, Company Dietitian for gluten-free food manufacturer Dr<br />

Schär who helped to fund this research, added:<br />

“Dr Schär were delighted to support Sheffield to conduct this research, the<br />

first study of it’s kind to compare all three major dietary interventions for<br />

IBS. The results will empower dietitians to suggest the most appropriate<br />

dietary treatment options for their IBS patients in a joint decision-making<br />

process. This study proves that, if advised on and followed correctly,<br />

traditional dietary advice can help the majority of IBS sufferers to find relief<br />

from their symptoms, without the need for more complex and costly dietary<br />

interventions. If traditional dietary advice fails, then there are further, equally<br />

effective options available to patients, including a gluten-free diet”.<br />

Further research is underway to build on these findings and provide<br />

further impetus for a medical consensus and future change in national<br />

guidance on IBS.<br />

6<br />

References<br />

1. Rej, A, Shaw C, Buckle R et al. The low FODMAP diet for IBS: A multicentre UK study assessing long-term followup.<br />

Dig Liver Dis 2021 Nov;53(11):1404-1411. Doi: 10.1016/j.dld.2021.05.004.Epub 2021 Jun 1<br />

2. Rej A, Sanders DS, Shaw CC, et al. Efficacy and Acceptability of Dietary Therapies in Non-Constipated Irritable<br />

Bowel Syndrome: A Randomized Trial of Traditional Dietary Advice, the Low FODMAP Diet and the Gluten-Free<br />

Diet. Clin Gastroenterol Hepatol. <strong>2022</strong> Feb 28: S1542-3565 (22) 00202-6. doi: 10.1016/j.cgh.<strong>2022</strong>.02.045.<br />

Online ahead of print<br />

3. Rej A, Buckle RL, Shaw CC, et al. National survey evaluating the provision of gastroenterology dietetic services in<br />

England. Frontline <strong>Gastroenterology</strong> 2020:flgastro-2020-101493.


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Endoscopy sees increased activity, but waiting lists remain challenging<br />

The recent record surge in the number of NHS patients being referred<br />

for cancer checks is part of a welcome increase in diagnostics activity as<br />

the NHS looks to refocus on waiting lists post-pandemic. Other areas of<br />

diagnostics have also seen an uptick. In colonoscopy and gastroscopy,<br />

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Criteria & Quality<br />

We select Endoscopists with an endoscopy<br />

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audit data is constantly monitored to ensure<br />

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Trusts shift to on-site mobile and modular theatre suites to better<br />

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The NHS is of course already engaged in this challenge and is rolling out<br />

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A particularly successful initiative however has been Trusts’ embracing<br />

of mobile and modular theatre units, usually located on-site, which have<br />

helped them focus on reducing waiting lists while keeping procedures<br />

separated from main hospital buildings, especially important given the<br />

need for safe Covid and general infection control.<br />

We provide tailored solutions to manage<br />

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patient pathway including pathology review.<br />

Here at 18 Week Support, the UK’s largest clinical insourcing provider,<br />

we have provided specialist endoscopy teams for a number of Trusts<br />

where we staff and operate mobile theatre units they have contracted<br />

from specialist providers such as Vanguard Healthcare Solutions.<br />

We have assisted over 55 Trusts around the country, carrying out the full<br />

range of endoscopy procedures either in-house or in mobile theatres,<br />

both during and after Covid-19. Indeed Trusts have been so pleased<br />

with the mobile and modular theatre suites concept that many are now<br />

including them in their planning for reducing waiting lists, adding new<br />

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Our commitment to improving the<br />

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Like the NHS Trusts we work with, patient<br />

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using any spare weekend capacity within a<br />

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in a short space of time, in the familiar<br />

surrounding of the NHS Trust.<br />

The experience of endoscopy delivery in modular mobile suites<br />

But what is the actual experience like for endoscopists to work in a<br />

stand-alone ‘cold site’?<br />

Dr Matthew Banks, Clinical Lead for 18 Week Support <strong>Gastroenterology</strong>,<br />

believes that although the experience is obviously new and has some<br />

specific challenges, adaptation to the new working environment can<br />

be rapid and relatively straightforward given 18 Week Support’s teams<br />

are mainly drawn from existing or recently retired NHS Consultants and<br />

nurses looking for extra shifts or to work part-time for a period.<br />

“Endoscoping in a mobile or semi-permanent endoscopy suite requires<br />

a degree of flexibility and adaptability. One needs to take time getting<br />

familiar with the unit, layout, equipment and IT. Once you have your<br />

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awareness, it is very much like scoping in any endoscopy unit”, said<br />

Staff do however need to be aware of the limitations. Matthew added,<br />

“Often you are isolated, with no, or very limited clinical back up and<br />

this dictates the level of complexity of the patients being endoscoped.<br />

Complex therapeutics and high-risk patients (ASA grade III/IV) are<br />

usually avoided, and the bulk of the work is straightforward diagnostic<br />

endoscopy”.<br />

Those working in insourcing teams like 18 Week Support will often find<br />

themselves working with different nurses through the course of a week,<br />

or over a longer period of time. Leadership, patience and understanding<br />

is needed to ensure the quality delivered is constant and of a high level.<br />

In addition, each unit team will typically have a Nurse in Charge (NIC)<br />

who runs the day and the lists. For consultants, focussing on their<br />

role as the endoscopist is key, and working as a team is essential in<br />

Happy patient<br />

ensuring all patients are managed appropriately. “Whilst in the room,<br />

the endoscopist needs to show leadership, but they also need to<br />

understand that someone else is actually in charge of the unit, and this<br />

can be a challenge for many consultant endoscopists”, said Matthew.<br />

Who we’re looking for<br />

Another “working-life” difference arises not from working in a mobile unit<br />

per We se, are but interested from working for in a third-party meeting organisation with Consultant<br />

within NHS<br />

Trust framework. This relationship necessarily means that patients are<br />

Gastroenterologists, senior nurses and clinical<br />

not followed up by the endoscopist, histology is often not available to<br />

review nurse after specialists the event and sometimes throughout clinical the information UK. can be quite<br />

limited. Moreover, because of the COVID pandemic, the endoscopist<br />

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years. The pre-procedure process is therefore key to understanding the<br />

Our remuneration package is second to<br />

patients concerns and ensuring the correct procedure is completed -<br />

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Haiyan Li 1 , Yao Liu 2 and Jianhong Zhu 1*<br />

Li et al. BMC <strong>Gastroenterology</strong> (<strong>2022</strong>) 22:148 https://doi.org/10.1186/s12876-022-02209-w<br />

Abstract<br />

Case presentation<br />

Background: Colorectal poorly differentiated adenocarcinoma is<br />

rarely founded, especially in early-stage. Endoscopic features of early<br />

poorly differentiated colorectal cancer in magnifying endoscopy and<br />

chromoendoscopy haven’t been clarified.<br />

Case presentation: A 49-year-old man was referred to our hospital<br />

for endoscopic treatment of a lateral spread tumor located in the<br />

rectum. We performed pre-resection endoscopic examination for the<br />

patient. In magnifying endoscopy with crystal violet staining, the lesion<br />

showed irregular microvessels and turned out to be poorly stained<br />

with predominantly non-structural pit pattern and a few roundish pits<br />

scattered on the surface. The histology revealed a poorly differentiated<br />

adenocarcinoma of the rectum invading the deep submucosal layer with<br />

negative lymphovascular invasion.<br />

Conclusions: In this case report, we presented a case of poorly<br />

differentiated colorectal adenocarcinoma detected at an early stage,<br />

showing interesting endoscopic findings in magnifying endoscopy with<br />

crystal violet staining.<br />

Keywords: Colorectal poorly differentiated adenocarcinoma, Magnifying<br />

endoscopy, Chromoendoscopy, De-novo colorectal cancer, Case report<br />

Background<br />

Colorectal poorly differentiated adenocarcinoma is rarely<br />

founded, especially in early-stage. Most cases are detected at an<br />

advanced stage. In contrast to differentiated adenocarcinoma,<br />

poorly differentiated adenocarcinoma often correlates with more<br />

aggressive biological behavior and is defined to be out-ofindication<br />

for endoscopic resection even in early-stage. Thus, the<br />

endoscopic diagnosis of poorly differentiated adenocarcinoma is<br />

important. Several endoscopic diagnostic classifications, including<br />

Kudo’s pit pattern classification, have been proposed and proved<br />

to distinguish colorectal cancer from non-neoplastic lesion or<br />

adenomas, as well as predict the depth of invasion in colorectal<br />

cancer. These diagnostic methods mostly focus on adenomas<br />

or differentiated adenocarcinomas. Perhaps due to its rarity,<br />

endoscopic features of early poorly differentiated colorectal cancer<br />

in magnifying endoscopy and chromoendoscopy haven’t been<br />

clarified. We here present a case of poorly differentiated colorectal<br />

cancer in the early-stage, showing specific findings in magnifying<br />

endoscopy with crystal violet staining.<br />

A 49-year-old man was referred to our hospital for endoscopic<br />

therapy of a lateral spread tumor (LST) in the rectum in December<br />

2019. At the previous hospital, biopsy histology showed high-grade<br />

intraepithelial neoplasia (HGIN). He had a three-week history of<br />

intermittent hematochezia. Family history for colorectal malignancy was<br />

negative. Physical examinations and routine laboratory tests revealed<br />

no abnormalities. Before resection, the patient underwent a magnifying<br />

chromoendoscopy examination. White-light endoscopy showed a<br />

superficially elevated lesion with slight depression in the central part,<br />

together with a reddish scar due to previous biopsy (Fig. 1A). The<br />

proximal part of the lesion presented with dense irregular microvessels<br />

in NBI mode (Fig. 1B). In magnifying endoscopy combined with 0.05%<br />

crystal violet staining, the proximal part showed irregular microvessels<br />

and turned out to be poorly stained with predominantly non-structural<br />

pit pattern, while the background mucosa showed regular Type-I pit<br />

patterns according to the Kudo’s classification (Fig. 1C). The distal part<br />

showed poorly stained with predominantly non-structural pit pattern,<br />

as well as a few small roundish pits scattered over the surface (Fig.<br />

1D). The demarcation line between the lesion and normal mucosa was<br />

clearly visible. The whole lesion was lifted after submucosal injection<br />

and then resected completely (Fig. 2A) through endoscopic submucosal<br />

dissection (ESD). Histology of the resected sample showed poorly<br />

differentiated adenocarcinoma invading into deep submucosal layer, with<br />

negative lymphovascular invasion and negative resection margin (Fig.<br />

2B–D). P53 Immunohistochemistry staining showed complete absence<br />

in the cancerous area, which was predictive of TP53 truncated mutation.<br />

The MMR and APC genes showed intact expression, and ß-catenin was<br />

expressed in the cellular membrane and cytoplasm (Fig. 3). KRAS gene<br />

mutation was conducted through Polymerase Chain Reaction (PCR)<br />

and also showed negative results. The patient then underwent additional<br />

surgery with lymph node dissection and final histology showed no<br />

residual tumor and no lymph node involvement. Follow-up surveillance<br />

colonoscopy and contrast enhanced computed tomography were<br />

performed for the patient in both the first year and second year after<br />

surgery. Neither local recurrence nor distant metastasis was detected<br />

over a two-year follow-up period.<br />

Discussion and conclusions<br />

Endoscopic resection is indicated for Tis or T1 tumors and<br />

pathological findings of unfavorable features including poorly<br />

differentiation and deep submucosal infiltration are considered to be<br />

non-curative [1]. Magnifying endoscopy with chemical dye staining<br />

is usually conducted for pre-resection assessment in these cases.<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

*Correspondence: zhujianhong1980@sina.com<br />

1<br />

Department of Gastroentorology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China<br />

2<br />

Department of Pathology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.<br />

©The Author(s) <strong>2022</strong><br />



Kudo’s pit pattern classification, which shows the relationship<br />

between pit patterns and histology, is accurate in differentiating<br />

neoplastic and non-neoplastic lesions and predicting tumor invasion<br />

depth. However, there has been no endoscopic diagnosing criteria<br />

in determining histologic type and tumor degree of differentiation<br />

for colorectal cancers. Reviewing the literature, we found a few<br />

case reports clarifying the endoscopic features of early-stage<br />

signet ring cell carcinoma in the colorectum [2,3,4]. To the best of<br />

our knowledge, there have been no reports on the magnifying nor<br />

the chromoendoscopic findings of poorly differentiated colorectal<br />

adenocarcinoma.<br />

Ohnita et al. [2] reported a primary signet ring cell carcinoma<br />

detected at an early stage. As they reported, the margin of the<br />

lesion showed IIIL and V I<br />

pit patterns, while the central part of the<br />

lesion showed V I<br />

pit pattern and dense mucus. Similar findings<br />

have been reported by Fu et al. [3]. As they explained, signet ring<br />

cells preferred to produce mucus so such lesions were difficult<br />

to stain and showed avascular areas. However, there was no<br />

obvious mucus in our case and the whole lesion was also difficult<br />

to stain using either indigo carmine or crystal violet. In our case,<br />

the histology revealed a large number of tumor cells overgrowing<br />

and loss of normal surface epithelium and crypt-like structure<br />

in the mucosal layer. These findings may explain why the lesion<br />

was poorly stained. In some histologic sections we observed a<br />

few normal glandular ducts surrounded by tumors cells (Fig. 2D),<br />

which was consistent with the scattered roundish pits, i.e., Type-I<br />

pit patterns in magnifying endoscopy. Minamide et al. [4] reported<br />

similar findings in colorectal signet ring cell carcinoma but the lesion<br />

was residual after cold snare polypectomy and the diagnosing<br />

information may be not adequate. In Kudo’s classification, Type V N<br />

pit-pattern refers to loss or decrease of pits with an amorphous<br />

structure and indicates invasive submucosal colorectal cancer.<br />

Usually, Type V N<br />

pit-pattern co-exists with Vi pit-pattern or scratch<br />

sign. The lesion in our case presented poorly stained feature with<br />

predominately non-structural pit pattern and a few roundish pits<br />

scattered on the surface. No obvious Vi pit-pattern or scratch sign<br />

was found. These features were different from those of typical Type<br />

V N<br />

pit-pattern in Kudo’s classification. We confused at the failing<br />

to stain the lesion in the beginning and we repeated several times<br />

and the outcomes turned out to be the same. Besides the poorly<br />

stained feature, the proximal part of the lesion showed irregular<br />

microvessels similar to corkscrew vessels which indicated poorly<br />

differentiated cancer in the stomach.<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

Fig. 1 A White light endoscopy revealed a lateral spread tumor in the rectum. B In near focus NBI mode, the proximal part of the lesion presented<br />

with dense irregular microvessels. C In magnifying endoscopy combined with 0.05% crystal violet staining, the proximal part of the lesion showed<br />

poorly stained with predominantly non-structural pit pattern, while the background mucosa showed regular Type-I pit patterns according to the<br />

Kudo’s classification. The demarcation line was clearly visible (white dotted line). D In magnifying endoscopy combined with 0.05% crystal violet<br />

staining, the distal part showed poorly stained with predominantly non-structural pit pattern and a few roundish pits (black arrow) scattered over<br />

the surface<br />



Fig. 2 A The lesion was en bloc resected. B The specimen was sectioned at 2 mm intervals. C Histology showed poorly differentiated colorectal<br />

cancer with partial submucosal infiltration (black arrow). Stain: hematoxylin and eosin. D In some sections, histology showed a few normal glandular<br />

ducts (black arrow) surrounded by tumors cells, which is corresponding to the endoscopic feature, i.e., small roundish pits scattered over the surface<br />

This was the first time we encountered with early poorly<br />

differentiated colorectal cancer and due to the lack of adequate<br />

knowledge, we initially performed endoscopic submucosal<br />

dissection for the patient. Non-curative endoscopic treatment<br />

resulted in increases in time and cost and decreased patient’s<br />

satisfaction. From our case, we suppose that poorly stained<br />

features with predominantly non-structural pit pattern in magnifying<br />

endoscopy with crystal violet staining may be related to poorly<br />

differentiation and thus be inappropriate for endoscopic resection.<br />

More researches are needed to make a definite conclusion.<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />



GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

Fig. 3 Immunohistochemistry staining of the lesion<br />

At the same time, we also analyzed the molecular features of the<br />

lesion. Colorectal cancers are heterogenous at the genetic level and<br />

develop via accumulation of genetic molecular alterations, in which<br />

APC, KRAS, TP53 mutations are mostly founded. Several pathways<br />

have been proposed for the development and progression of colorectal<br />

cancer, including the widely accepted adenoma-carcinoma sequence,<br />

the serrated neoplasia pathway, and de-novo carcinogenesis [5].<br />

By definition, de-novo lesions are characterized by the lack of any<br />

adenomatous remnant. In our case, the lesion presented with<br />

nonpolypoid growth pattern and no adenomatous remnant was founded.<br />



Immunohistochemical and molecular analysis of the lesion implied p53<br />

mutation, without any of APC, ß-catenin, or KRAS mutation. Thus, we<br />

suppose that the cancerous lesion in our case is associated with p53<br />

mutation, in accordance with molecular changes of de-novo colorectal<br />

cancers.<br />

of Pathology, The Second Affiliated Hospital of Soochow University,<br />

Suzhou, Jiangsu Province, China.<br />

Received: 6 August 2021 Accepted: 12 March <strong>2022</strong><br />

Published online: 28 March <strong>2022</strong><br />

Availability of data and materials<br />

All data generated or analysed during this study are included in this<br />

published article.<br />

Abbreviations<br />

LST: Lateral spread tumor; HGIN: High-grade intraepithelial neoplasia;<br />

NBI: Narrow band imaging; ESD: Endoscopic submucosal dissection;<br />

P53: Protein 53; TP53: Tumor protein 53; MMR: Mismatch repair<br />

proteins; MSH2: MutS homolog 2; MSH6: MutS homolog 6; MLH1:<br />

MutL homolog 1; PMS2: Postmeiotic segregation increased 2; APC:<br />

Adenomatous polyposis coli; KRAS: Kirsten rat sarcoma viral oncogene<br />

homolog; PCR: Polymerase chain reaction.<br />

Acknowledgements<br />

Not applicable.<br />

Authors’ contributions<br />

HL conducted this report and prepared the manuscript. JZ performed<br />

the colonoscopy and provided the endoscopic images. YL performed<br />

the histological examination and provided the histology images. All<br />

authors read and approved the final manuscript.<br />

References<br />

1. Shinagawa T, Tanaka T, Nozawa H, et al. Comparison of the<br />

guidelines for colorectal cancer in Japan, the USA and Europe. Ann<br />

Gastroenterol Surg. 2017;2(1):6–12.<br />

2. Ohnita K, Isomoto H, Akashi T, et al. Early stage signet ring cell<br />

carcinoma of the colon examined by magnifying endoscopy with<br />

narrow-band imaging: a case report. BMC Gastroenterol. 2015;15:86.<br />

3. Fu KI, Sano Y, Kato S, et al. Primary signet-ring cell carcinoma of the<br />

colon at early stage: a case report and a review of the literature. World<br />

J Gastroenterol. 2006;12:3446–9.<br />

4. Minamide T, Shinmura K, Ikematsu H, et al. Early-stage primary signet<br />

ring cell carcinoma of the colon with magnifying endoscopic findings.<br />

Gastrointest Endosc. 2019;90:529–31.<br />

5. Papagiorgis PC, Zizi AE, Tseleni S, et al. Clinicopathological differences<br />

of colorectal cancers according to tumor origin: identification of possibly<br />

de novo lesions. Biomed Rep. 2013;1:97–104.<br />

Publisher’s Note<br />

Springer Nature remains neutral with regard to jurisdictional claims in<br />

published maps and institutional affiliations.<br />

ScheBo_Gastro<strong>Today</strong> 29/04/<strong>2022</strong><br />

Funding<br />

This work was supported by the Doctoral Program Foundation of<br />

the Second Affiliated Hospital of Soochow University (Grant No.<br />

SDFEYJBS2102), the Scientific Research Foundation of the Second<br />

Affiliated Hospital of Soochow University (Grant No. SDFEYQN1811),<br />

and the discipline construction and support project of the Second<br />

Affiliated Hospital of Soochow University (Grant No. XKTJ-JD202006).<br />

Funding enabled immunohistochemical and genetic analysis of the<br />

resected sample. The funder did not influence the collection and analysis<br />

of data, the decision to publish and the writing of the manuscript.<br />

Availability of data and materials<br />

All data generated or analysed during this study are included in this<br />

published article.<br />

Declarations<br />

Ethics approval and consent to participate<br />

Not applicable.<br />

Consent for publication<br />

Written informed consent was obtained from the patient for publication<br />

of this case report and any accompanying images.<br />

Competing interests<br />

The authors declare that they have no competing interests.<br />

Author details<br />

1<br />

Department of Gastroentorology, The Second Affiliated Hospital of<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

Soochow University, Suzhou, Jiangsu Province, China. 2 Department<br />


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Wang Jing 1† , Li Qinghua 1† and Yang Zhiwen 2*<br />

Jing et al. BMC <strong>Gastroenterology</strong> (<strong>2022</strong>) 22:156 https://doi.org/10.1186/s12876-022-02218-9<br />

Abstract<br />

Background<br />

Postpolypectomy fever (PPF) is a rare complication in patients after<br />

colonoscopy. Because of the absence of evidence of microperforation<br />

and abdominal tenderness, patients with PPF usually present mild<br />

clinical symptoms with a good prognosis.<br />

Case presentation<br />

In this study, all patients who underwent colonoscopic examination in our<br />

hospital between January 2019 and December 2019 were enrolled. Of<br />

these, two patients developed PPF after polypectomy, exhibiting serious<br />

infection without definitive fever foci. One patient experienced rapidly<br />

aggravated type 1 respiratory failure and abnormal hepatic function, which<br />

were attributed to colonoscopy-associated infection. After active antibiotic<br />

therapy, both patients were discharged without any complications.<br />

Conclusions<br />

In summary, our study provides novel insights into patients with PPF<br />

who develop serious infections with life-threatening complications.<br />

Keywords<br />

Postpolypectomy fever, Serious infection, Diagnose, Therapy, Patient<br />

Background<br />

overlooked in clinical practice, owing to the absence of typical peritoneal<br />

irritation and definitive fever foci. Thus, our report should aid in timely<br />

diagnosis and appropriate therapy for patients with PPF.<br />

Case presentation<br />

Case selection, procedures, and definitions<br />

In 2019, 12,000 patients underwent colonoscopic examination in our<br />

hospital, and approximately 2000 patients with gastrointestinal polyps<br />

received painless endoscopic treatment. These cases of colonoscopies<br />

were performed in the outpatient and inpatient setting. All colonoscopies<br />

were elective, not urgent. Patients who received polypectomy were<br />

admitted to the hospital for about 2–3 days. Two patients after<br />

colonoscopy met the inclusion criteria with a high fever up to 39.0 °C in<br />

1–2 h, and the leukocytes, C-reactive protein (CRP) and procalcitonin<br />

(PCT) increased significantly with signs of infection [5,6,7]. They were a<br />

health state at admission, without any signs of fever, abdominal pain,<br />

cough, frequent urination, infection or other discomfort. The results<br />

of routine analyses of the blood, urine and feces were normal, and no<br />

signs of infection were observed on chest ` abdominal CT. The patients<br />

developed serious infections after polypectomy during hospitalization.<br />

Physical and radiographic examination did not show evidence of<br />

perforation, hemorrhage, abdominal tenderness or localized peritoneal<br />

inflammation. No evidence of other explainable fever foci other than<br />

colonoscopic polypectomy was identified.<br />

Colonoscopy is widely used in clinical practice, although serious<br />

complications may result from colonoscopic polypectomy [1, 2]. These<br />

serious complications are inherent to the procedure and occur at low<br />

incidence during colonoscopy. Hemorrhage and perforation, the most<br />

feared complications, occur in ≤ 0.3% and 0.3–0.6% [3, 4], respectively.<br />

Postpolypectomy electrocoagulation syndrome (PPCS), a rare<br />

complication, ranges from 0.07 to 1.0% [3, 4].<br />

Here, we report the cases of two patients who developed PPF after<br />

colonoscopy, and experienced new-onset fever without localized<br />

peritoneal signs or definitive fever foci. Aggravated serious infectious<br />

symptoms were present with a high fever up to 39.0 °C in 1–2 h after<br />

operation, and the patients received further therapy in the general<br />

intensive care unit (GICU). As reported previously, patients with PPF<br />

generally present mild clinical symptoms with good prognosis. To our<br />

knowledge, this is the first report of patients with PPF developing serious<br />

infections with life-threatening complications. Additionally, PPF is easily<br />

Patients with postpolypectomy bleeding, microperforation, abdominal<br />

tenderness, localized peritoneal inflammation and infection associated<br />

with definitive fever foci other than colonoscopic polypectomy were<br />

excluded.<br />

All colonoscopic polypectomies were performed with standard<br />

colonoscopes (CF-H260AL; Olympus Optical Co., Ltd., Tokyo, Japan).<br />

Patients were slowly intravenously injected with propofol. Patients who<br />

received polypectomy operation were admitted to the hospital for about<br />

2–3 days.<br />

Patient 1<br />

The first case was in a 50-year-old man without a notable past history,<br />

who was diagnosed with multiple colorectal polyps. Four polyps were<br />

found: three flat polyps with a diameter of 2–5 mm in the sigmoid colon<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

*Correspondence: yangzhiwen2009@sina.com † Wang Jing and Li Qinghua have contributed equally to this work<br />

1<br />

Department of <strong>Gastroenterology</strong>, Songjiang District Central Hospital, Shanghai, China 2 Department of Pharmacy, Songjiang District Central Hospital, Shanghai 201600, China<br />

©The Author(s) <strong>2022</strong><br />



(Fig. 1A, B) and a flat polyp with a diameter of 4 mm in the rectum<br />

(Fig. 1C). He underwent colonoscopy with cold biopsy of a 4 mm rectal<br />

polyp (Fig. 1D), and the colorectal polyps were confirmed pathologically.<br />

Two hours after the operation, the patient developed a high fever<br />

up to 39.4 °C. Laboratory examinations revealed elevated infection<br />

indices, such as PCT 44.52 ng/mL, CRP 40.48 mg/L, white blood<br />

cell count (WBC) 17.3 × 10 9 /L and neutrophils 95.4%. The result of<br />

CT scan showed pleural effusion in lung (Fig. 2 A and B). No evidence<br />

of other explainable fever foci was found, and no microorganisms<br />

were found in blood cultures. Because of the serious colonoscopyassociated<br />

infection, the patient was transferred to the GICU and<br />

treated with antibiotic combined therapy consisting of meropenem<br />

(1.0 g administered intravenously every 12 h) and metronidazole (0.5 g<br />

administered intravenously every 12 h). His fever subsided within 1 day,<br />

thus indicating that the antibiotic therapy was effective. Eventually, the<br />

patient was discharged without any complications.<br />

Fig. 1 Colonoscopic examination of a 50-year-old man. A A flat<br />

polyp with a diameter of 3 mm in the sigmoid colon. B Two flat<br />

polyps with diameters of 3–5 mm in the sigmoid colon. C A flat polyp<br />

with a diameter of 4 mm in the rectum; D Rectal biopsy<br />

Patient 2<br />

The second case was in a 72-year-old woman with a history of<br />

hypertension and fatty liver, who underwent a colonoscopy that revealed<br />

13 polyps: four flat polyps with a diameter of 2–3 mm in the ileocecal part<br />

(Fig. 3A), a 4 mm papillary polyp in the liver flexure of the colon (Fig. 3B),<br />

a 3 mm flat polyp in the transverse colon (Fig. 3C) and seven flat polyps<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

Fig. 2 chest and abdominal CT before and after colonoscopy. A Chest CT of a 50-year-old man. Normal CT before colonoscopy, but abnormal CT<br />

with pleural effusion after colonoscopy. B Abdominal CT of a 50-year-old man. Normal CT before and after colonoscopy. C Chest CT of a 72-year-old<br />

woman. Normal CT before colonoscopy, but abnormal CT with pleural effusion after colonoscopy. D Abdominal CT of a 72-year-old woman.<br />

Normal CT before colonoscopy, but abnormal CT with exudation in pancreas tail after colonoscopy<br />



with diameters of 2–5 mm in the sigmoid colon (Fig. 3D). The colorectal<br />

polyps confirmed pathologically were resected by argon plasma<br />

coagulation (APC) under the condition of strong electrocoagulation<br />

2, 40 W APC power, and 0.8–1.2 L/min argon gas flow (APC ® 2 and<br />

electric generator vio ® 200D; ERBE Company, Tuebingen, German). One<br />

hour after the operation, the patient suddenly developed a high fever<br />

of 39.0°C, without cough, expectoration or abdominal pain. On the<br />

morning of the second day, the patient’s body temperature continued<br />

to rise to 40.0°C, Physical examination findings for the abdomen were<br />

negative, without evidence of intestinal perforation and hemorrhage.<br />

There was no abnormalities in routine urine examination, and no<br />

bacterial growth in blood culture examination. Laboratory examinations<br />

revealed 18.48 × 10 9 /L WBC, 96.1% neutrophils, more than 100.0 ng/<br />

mL procalcitonin, 68.24 mg/L CRP. The result of CT scan showed<br />

pleural effusion in lung and exudation in pancreas tail (Fig. 2 C and D).<br />

Of note, the patient’s illness rapidly worsened, and she was transferred<br />

to the GICU, with poor gas analysis (PH7.384, PCO2 34.8 mmHg, PO2<br />

42.1 mmHg) and abnormal hepatic function results (ALT 145.9U/L, AST<br />

256.5U/L, r-GT 215U/L). After consultation with doctors, the patient’s<br />

symptoms, including type 1 respiratory failure and abnormal hepatic<br />

functions, were attributed to a colonoscopy-associated infection with<br />

subsequent gut bacterial translocation. The patient received intravenous<br />

therapy consisting of 1.0 g of vancomycin every 12 h for 3 days, and<br />

1.0 g of imipenem/cilastatin every 8 h for 5 days. After 2 days of therapy,<br />

her body temperature normalized. The patient’s gas analysis (PH7.439,<br />

PCO 2<br />

33.9 mmHg, PO 2<br />

93.3 mmHg) and liver function (ALT 27.74U/L,<br />

AST 20.99U/L, r-GT 67.79U/L) also recovered normally. Eventually, she<br />

was discharged without any complications.<br />

Discussion and conclusions<br />

In previously published reports, PPF has been considered a rare<br />

complication of colonoscopic polypectomy with slight clinical<br />

symptoms and good prognosis [5, 8]. To our knowledge, this study<br />

is the first report of patients with PPF presenting serious infectious<br />

symptoms leading to life-threatening complication, and rapid<br />

deterioration to type 1 respiratory failure and abnormal hepatic<br />

function. After antibiotic therapy, the patient condition rapidly<br />

recovered.<br />

Fig. 3 Colonoscopic examination of a 72-year-old woman. A Four<br />

flat polyps with diameters of 2–3 mm in the ileocecal part. B A 4 mm<br />

papillary polyp in the liver flexure of the colon. C A 3 mm flat polyp in<br />

the transverse colon. D Seven flat polyps with diameters of 2–5 mm<br />

in the sigmoid colon<br />

Seven patients were previously reported to develop PPF after<br />

colonoscopic polypectomy, of which four cases had a polyp<br />

diameter ≥ 2 cm, one case had a polyp 10–30 mm in diameter, and<br />

two cases had no polyps [5]. The median initial time of fever after<br />

polypectomy was approximately 7 h, and the median fever duration<br />

was approximately 9 h [5]. The seven patients with PPF had slight<br />

clinical symptoms with a good prognosis after antibiotic therapy [5].<br />

CRP, a critical infection index, did not increase within 24 h [5]. In<br />

contrast to these cases, three exceptional findings in our study were<br />

observed. First, severe infection in patients with PPF was found,<br />

thus resulting in type 1 respiratory failure and abnormal hepatic<br />

function. Second, the patients with PPF had relatively smaller polyps<br />

of 2–5 mm in diameter. Third, CRP and PCT were significantly<br />

elevated within several hours.<br />

Lee et al. further discussed three possible mechanisms of PPF<br />

[5, 8]. The first is that PPF may be a mild form of PPCS that<br />

develops by transmural burn. With the exception of abdominal<br />

tenderness, PPF is similar in terms other clinical symptoms and<br />

risk factors to PPCS. Notably, transmural burn in the colon wall<br />

is significant in both PPF and PPCS, thus suggesting that both<br />

might be generated by the same mechanism. PPF and PPCS are<br />

initiated by different degrees of transmural burn, with or without<br />

actual intestinal perforation. The second is that gut bacteria may<br />

translocate to the bloodstream via mucosal wounds during the<br />

colonoscopic procedure. The incidence of transient bacteremia was<br />

approximately 4% within 10 min after polypectomy. Contamination<br />

by enteric bacteria is inevitable, even when a disinfected colonoscope,<br />

sterile needles and sterile injection fluid are used during colonoscopy [9-<br />

11]. For instance, the propofol formulation for intravenous administration<br />

may be a possible contamination factor [12]. The third is that PPF may<br />

be attributable to an inflammatory mechanism other than infection.<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />



GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

In general, polyps induce an inflammatory microenvironment<br />

with inflammatory cell infiltration and elevated proinflammatory<br />

cytokines, such as IL-6 and TNF-α. Thus, determining whether the<br />

patients with PPF developed fever because of the colonoscopy or the<br />

polypectomy itself is difficult.<br />

As previously reported, seven patients developed PPF, of which two<br />

cases had no polyps, and one case had polyps 10–30 mm in diameter<br />

[5]. This finding suggests that colonoscopic examination without<br />

colonoscopic polypectomy also affects the intestinal bacteria or causes<br />

minimal intestinal-barrier damage. The patients with PPF in our study<br />

had multiple relatively small polyps (2–5 mm in diameter), in contrast<br />

to the previously reported findings. Although the causes of PPF are<br />

complicated, we believe that gut bacteria are translocated to the<br />

bloodstream via mucosal wounds.<br />

PPCS, a rare and serious complication of colonoscopic polypectomy,<br />

results from an electrocoagulation injury to the bowel wall during<br />

polypectomy, which induces a transmural burn and localized peritoneal<br />

inflammation without clinical evidence of perforation on radiographic<br />

examination [13]. Within hours to 5 days after colonoscopic<br />

polypectomy, patients develop fever and other symptoms, including<br />

leukocytosis, localized abdominal pain and localized peritoneal signs.<br />

In summary, this study may increase clinical awareness regarding PPF<br />

after colonoscopy. Early recognition and antibiotic therapy are critical,<br />

which can improve patient prognosis and avoid severe outcomes.<br />

Abbreviations<br />

PPF: Postpolypectomy fever; PPCS: Postpolypectomy<br />

electrocoagulation syndrome; GICU: General intensive care unit; CRP:<br />

C-reactive protein; PCT: Procalcitonin; WBC: White blood cell count;<br />

APC: Argon plasma coagulation.<br />

Acknowledgements<br />

This study was supported by all physicians in the Department of<br />

<strong>Gastroenterology</strong>, Songjiang District Central Hospital, Shanghai, China.<br />

We thank International Science Editing for editing this manuscript.<br />

Authors’ contributions<br />

JW and QL designed the study. ZY analyzed data and wrote the<br />

manuscript. All authors have read and approved the final manuscript.<br />

Funding<br />

This case report was supported by Shanghai Municipal Health<br />

Bureau (201940471) and Shanghai Songjiang Science & Technology<br />

Commission (2017sjkjgg50), which supported data collection, analysis<br />

and manuscript writing.<br />

Availability of data and materials<br />

All information about the patient come from department of<br />

<strong>Gastroenterology</strong>, Songjiang District Central Hospital. The data used and<br />

analyzed during the current study are included in this article.<br />

Declarations<br />

Ethics approval and consent to participate<br />

Not applicable.<br />

Consent for publication<br />

The two patients gave written consent for their personal or clinical<br />

details along with any identifying images to be published in this study.<br />

Competing interests<br />

The authors declare no conflicts of interest.<br />

Author details<br />

1<br />

Department of <strong>Gastroenterology</strong>, Songjiang District Central Hospital,<br />

Shanghai, China. 2 Department of Pharmacy, Songjiang District Central<br />

Hospital, Shanghai 201600, China.<br />

Received: 8 October 2021 Accepted: 16 March <strong>2022</strong><br />

Published online: 29 March <strong>2022</strong><br />

References<br />

1. Barua I, Vinsard DG, Jodal HC, Løberg M, Kalager M, Holme Ø, et<br />

al. Performance of artificial intelligence in colonoscopy for adenoma<br />

and polyp detection: a systematic review and meta-analysis.<br />

Gastrointest Endosc. 2021;93(1):277–85.<br />

2. Benazzato L, Zorzi M, Antonelli G, Guzzinati S, Hassan C, Fantin<br />

A, et al. Colonoscopy-related adverse events and mortality in an<br />

Italian organized colorectal cancer screening program. Endoscopy.<br />

2021;53(5):501–8.<br />

3. Watabe H, Yamaji Y, Okamoto M, Kondo S, Ohta M, Ikenoue T, et<br />

al. Risk assessment for delayed hemorrhagic complication of colonic<br />

polypectomy: polyp-related factors and patient-related factors.<br />

Gastrointest Endosc. 2006;64(1):73–8.<br />

4. Arora G, Mannalithara A, Singh G, Gerson LB, Triadafilopoulos<br />

G, et al. Risk of perforation from a colonoscopy in adults: a large<br />

population-based study. Gastrointest Endosc. 2009;69(3 Pt<br />

2):654–64.<br />

5. Lee SH, Kim KJ, Yang DH, Jeong KW, Ye BD, Byeon JS, et al.<br />

Postpolypectomy fever, a rare adverse event of polypectomy:<br />

nested case-control study. Clin Endosc. 2014;47(3):236–41.<br />

6. Waye JD, Lewis BS, Yessayan S. Colonoscopy: a prospective report<br />

of complications. J Clin Gastroenterol. 1992;15(4):347–51.<br />

7. Waye JD, Kahn O, Auerbach ME. Complications of colonoscopy<br />

and flexible sigmoidoscopy. Gastrointest Endosc Clin N Am.<br />

1996;6(2):343–77.<br />

8. Kim HW. What is different between postpolypectomy fever<br />

and postpolypectomy coagulation syndrome? Clin Endosc.<br />

2014;47(3):205–6.<br />

9. Levy MJ, Norton ID, Clain JE, Enders FB, Gleeson F, Limburg PJ,<br />

et al. Prospective study of bacteremia and complications with EUS<br />

FNA of rectal and perirectal lesions. Clin Gastroenterol Hepatol.<br />

2007;5(6):684–9.<br />

10. Low DE, Shoenut JP, Kennedy JK, Sharma GP, Harding GK, Den<br />

Boer B, et al. Prospective assessment of risk of bacteremia with<br />

colonoscopy and polypectomy. Dig Dis Sci. 1987;32(11):1239–43.<br />

11. Nelson DB. Infectious disease complications of GI endoscopy: part<br />

II, exogenous infections. Gastrointest Endosc. 2003;57(6):695–711.<br />

12. Rex DK, Deenadayalu V, Eid E. Gastroenterologist-directed propofol:<br />

an update. Gastrointest Endosc Clin N Am. 2008;18(4):717–25.<br />

13. Kus J, Haque S, Kazan-Tannus J, Jawahar A. Postpolypectomy<br />

coagulation syndrome—an uncommon complication of<br />

colonoscopy. Clin Imaging. 2021;79:133–5.<br />

Publisher’s Note<br />

Springer Nature remains neutral with regard to jurisdictional claims in<br />

published maps and institutional affiliations.<br />




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The GastroPanel Quick Test is now available in the UK. For more<br />

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The debilitating gut<br />

condition affecting<br />

thousands of women<br />

New resources published today by Guts UK<br />

to raise awareness of microscopic colitis<br />

show that women are 700% more likely<br />

than men to suffer with the condition.<br />

The charity is calling for more research to<br />

determine the reasons behind this gender<br />

disparity in the hope it will lead to prevention,<br />

faster diagnoses and developments in<br />

treatments.<br />

Microscopic colitis is an inflammation of the<br />

large intestine (bowel) that causes persistent,<br />

frequent and watery diarrhoea (throughout the<br />

day and night), stomach pain, fatigue, faecal<br />

incontinence and weight loss. The charity has<br />

chosen to create specific resources for women<br />

as part of Microscopic Colitis Awareness Week<br />

after research has shown that 87.5% of people<br />

suffering with the condition are female - most<br />

of whom are diagnosed between the ages of<br />

50 and 70. [1] [2]<br />

Microscopic colitis is a leading cause of<br />

diarrhoea in older adults and it can have a<br />

devastating impact on a person’s quality of life.<br />

Scientists estimate that around 67,200 people<br />

are living with microscopic colitis in the UK.<br />

[3] [4]<br />

Patients often find it difficult to manage<br />

jobs, socialise, travel and take part in family<br />

life because of the urgent nature of their<br />

symptoms and their need to be near to toilet<br />

facilities at all times. Coping with this often<br />

leaves sufferers feeling very isolated and can<br />

have a significant and detrimental effect on<br />

their mental wellbeing.<br />

Many people suffer for years with microscopic<br />

colitis but the correct diagnosis and treatment<br />

can make a huge and dramatic difference to a<br />

person’s quality of life.<br />

Julie, aged 42 from Sidcup in Kent, was<br />

diagnosed with microscopic colitis in 2020.<br />

Julie said:<br />

“The symptoms of microscopic colitis are<br />

awful. I experienced crippling stomach pain,<br />

nausea as well as watery diarrhoea which<br />

lasted for several weeks and only stopped<br />

when I was diagnosed and began a treatment<br />

of steroids. It all had a massive impact on<br />

mental health since this was during lockdown<br />

and I worried about what could be wrong.<br />

“It’s a very isolating condition and I can<br />

understand why it’s called a hidden disability.<br />

It’s been over a year since I was diagnosed<br />

and I’m still having flare-ups. I am constantly<br />

thinking about what I am eating and when I<br />

am out where the nearest facilities are - it’s<br />

exhausting.”<br />

At least 1 in 1,000 people are thought to have<br />

microscopic colitis in the UK with 17,000 new<br />

cases being diagnosed each year, but the real<br />

number could be a lot higher because it’s often<br />

underreported and misdiagnosed.[5] [6] One<br />

study showed that one in three patients<br />

with microscopic colitis were initially<br />

incorrectly diagnosed with Irritable Bowel<br />

Syndrome. [7] It is also a growing disease and<br />

the number of patients diagnosed has been<br />

increasing over the past 20 years. [8]<br />

Microscopic colitis is named because, unlike<br />

other inflammatory bowel diseases (IBD), like<br />

Crohn’s disease or ulcerative colitis, it can’t<br />

be diagnosed with a colonoscopy alone and a<br />

sample of tissue taken from the bowel must be<br />

examined under a microscope to identify the<br />

condition. However, once confirmed, treatment<br />

with prescribed medicine (a steroid called<br />

budesonide) is available and has shown to be<br />

very effective and often life-changing. [9]<br />

The causes of microscopic colitis and the<br />

reason it affects women disproportionately<br />

are still unclear. As it is a relatively new<br />

disease (first described in 1976) it has led<br />


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NEWS<br />

to a presumption that it is environmental<br />

as opposed to genetic factors that are<br />

responsible for its occurrence. [10]<br />

have to, so my main message this Microscopic<br />

Colitis Awareness Week is don’t suffer in<br />

silence and seek help from your GP if you’re<br />

experiencing symptoms.”<br />

[10] https://www.ncbi.nlm.nih.gov/pmc/<br />

articles/PMC8776530/#B4<br />

[11] Lansoprazole and omeprazole are the<br />

most commonly known.<br />

Prior studies have suggested that a range of<br />

medications including proton pump inhibitors<br />

(PPIs) - which are used to reduce stomach<br />

acid [11], nonsteroidal anti-inflammatory drugs<br />

such as ibuprofen, statins, antidepressants,<br />

aspirin, and beta blockers may be associated<br />

with the disease as well as cigarette smoking<br />

and a co-diagnosis of an auto-immune<br />

disease. [12] [13]<br />

What is clear is that women are at substantially<br />

higher risk of having microscopic colitis<br />

than men. [14] Despite this marked gender<br />

discrepancy, the literature on reproductive<br />

and hormonal factors is very limited. Some<br />

scientists have hypothesised that there is a<br />

link with microscopic colitis and the use of<br />

oral contraceptive pills and HRT [15] but more<br />

research is needed for this to be conclusive.<br />

Julie Harrington, CEO of Guts UK, said:<br />

“Thousands of people across the country are<br />

quite literally housebound with symptoms of<br />

microscopic colitis and we now know that<br />

the rates are increasing and are likely to grow<br />

further as the population ages.<br />

“Further research is desperately needed to<br />

identify risk factors and find out why women<br />

are far more likely to suffer from microscopic<br />

colitis so we can move to a place where<br />

prevention and faster diagnosis is possible.<br />

“In the meantime, I hope that this year’s<br />

Microscopic Colitis Awareness Week will raise<br />

awareness of this extremely difficult condition<br />

and that sufferers discover the simple<br />

treatments that can make a huge and dramatic<br />

difference to their quality of life.”<br />

Professor Shaji Sebastian, Consultant<br />

Gastroenterologist at Hull University Teaching<br />

Hospitals NHS Trust and Guts UK trustee added:<br />

“Scientists still don’t fully understand what<br />

causes microscopic colitis and further research<br />

is clearly needed to determine what could be a<br />

combination of factors.<br />

“What we do know is that the condition can<br />

be very debilitating but with the right tests it’s<br />

also very treatable. Early diagnosis is crucial to<br />

prevent patients from suffering when they don’t<br />

Julie from Sidcup added:<br />

“There is very little awareness of microscopic<br />

colitis, but I am sure there are many people<br />

suffering with it without knowing. My<br />

message for anyone with symptoms is that<br />

if you feel that things aren’t quite right and<br />

you’re struggling to get a diagnosis then<br />

persevere and push for an appointment with<br />

a gastroenterologist. The treatments available<br />

can certainly improve symptoms.”<br />

Anyone experiencing symptoms is advised<br />

to see their GP, contact Guts UK for more<br />

information or visit gutscharity.org.uk<br />

#MicroscopicColitisAwareness<br />

[1] 7:1 female to male meaning 87.5%<br />

of people with the condition are<br />

women and women are 700x more<br />

likely to have the condition than men:<br />

https://drive.google.com/drive/u/2/<br />

folders/1LxFK0CEv_1JqSLrfg-Vp7p179T_<br />

hxYBP - Other studies have said it may<br />

be as high as 9:1.<br />

[2] https://gutscharity.org.uk/advice-andinformation/conditions/microscopiccolitis-2/<br />

[3] https://www.ncbi.nlm.nih.gov/pmc/<br />

articles/PMC8776530/<br />

[4] Aprox. 67,222 people are living with<br />

Microscopic Colitis in the UK - around<br />

59,000 women and 8,000 men.<br />

[5] https://www.crohnsandcolitis.org.uk/<br />

about-crohns-and-colitis/publications/<br />

microscopic-colitis<br />

[6] Tong J et al. Am J Gastroenterol 2015;<br />

110(2): 265-76. Office for National<br />

Statistics. Statistical Bulletin: 26 June<br />

2019.https://pubmed.ncbi.nlm.nih.<br />

gov/25623658/<br />

[7] Limsui D et al. Inflamm Bowel Dis 2007:<br />

13(2): 175-81 https://www.ncbi.nlm.nih.<br />

gov/pmc/articles/PMC4754103/<br />

[8] Münch A, Aust D, Bohr J, Bonderup O,<br />

Fernández Bañares F, Hjortswang H, et<br />

al. Microscopic colitis: current status,<br />

present and future challenges: statements<br />

of the European Microscopic Colitis<br />

Group. J Crohns Colitis (2012) 6(9):932–<br />

45. doi:10.1016/j.crohns.2012.05.014<br />

PubMed Abstract | CrossRef Full Text |<br />

Google Scholar<br />

[9] https://gutscharity.org.uk/advice-andinformation/conditions/microscopiccolitis-2/<br />

[12] https://www.ncbi.nlm.nih.gov/pmc/<br />

articles/PMC8776530/<br />

[13] https://www.crohnsandcolitis.org.uk/<br />

about-crohns-and-colitis/publications/<br />

microscopic-colitis<br />

[14] Weimers P, Ankersen DV, Lophaven S,<br />

Bonderup OK, Münch A, Løkkegaard<br />

ECL, Burisch J, Munkholm P. Incidence<br />

and prevalence of microscopic colitis<br />

between 2001 and 2016: A Danish<br />

nationwide cohort study. J Crohns Colitis.<br />

2020 [PubMed] [Google Scholar]<br />

[15] https://www.ncbi.nlm.nih.gov/pmc/<br />

articles/PMC8776530/<br />

Health care professionals<br />

urged to ‘think EOE’ for<br />

patients suffering from<br />

dysphagia or food bolus<br />

obstruction<br />

An easily treatable, upper GI condition<br />

which causes dysphagia and food bolus<br />

obstruction, is going undiagnosed,<br />

sometimes for years, 1 leaving thousands of<br />

sufferers needlessly living with significant<br />

discomfort, anxiety and embarrassment.<br />

Additionally, Eosinophilic Oesophagitis<br />

(EoE) is known to be the most common<br />

single reason for attendance at A&E for<br />

food bolus obstruction removal. 2 Yet<br />

despite this, EoE - which is believed to<br />

affect around 23,500 people in the UK 2 –<br />

takes on average up to eight years to be<br />

diagnosed. 3<br />

Now the UK charity EOS Network is running<br />

a clinical and public awareness campaign<br />

urging both the general public and healthcare<br />

professionals, in particular A & E doctors and<br />

nurses, GPs and practice nurses, to ‘Think<br />

EoE’. During the Awareness Week, volunteers<br />

will be visiting GP surgeries with patient leaflets<br />

and posters whilst the EOS Network clinical<br />

community are being encouraged to put up<br />

‘Think EoE’ posters in their staffrooms.<br />

Eosinophilic Oesophagitis (EoE) is an immunemediated<br />

disease, most probably caused by<br />

food allergies or other environmental ‘triggers’<br />

which occurs in the upper gut or oesophagus.<br />


This results in inflammation of the mucosa in<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />


NEWS<br />

the oesophagus which, if left untreated, can<br />

lead to oesophageal remodelling including the<br />

formation of furrows leading to strictures. In turn<br />

this creates the difficulties with swallowing food.<br />

Sufferers of Eosinophilic Oesophagitis (EoE) will<br />

typically have a history of ‘slow eating,’ drinking<br />

lots of water whilst eating and avoiding tough,<br />

chewy or starchy foodstuff such as meat, rice<br />

and bread. They are often labelled ‘fussy eaters’<br />

and may avoid social eating occasions for fear<br />

of choking, coughing or retching in public.<br />

EoE was identified as a disease in the 1990s,<br />

yet many primary care physicians are still<br />

unaware of the condition, often mistaking it<br />

for GORD (gastro-oesophageal reflux disease)<br />

or dyspepsia, 4 whilst patients admitted to<br />

A&E with food bolus obstruction will typically<br />

be referred back to their GP rather than to a<br />

gastroenterologist.<br />

An EoE diagnosis requires 6 biopsies taken<br />

from at least 2 sites in the oesophagus to<br />

specifically count the number of eosinophils<br />

present. Yet whilst diagnosis is relatively<br />

straightforward, lack of clinical awareness<br />

means that opportunities are often missed,<br />

and the patient can spend years going<br />

between GP and hospital in a search for the<br />

cause of their discomfort. Some patients have<br />

even been told that the condition is caused by<br />

psychological issues.<br />

‘Whether it is at primary care level, at A&E<br />

or even during referral to a gastroenterology<br />

department, far too many of our members<br />

are reporting years of missed opportunities<br />

for diagnosis at every step of their disease<br />

journey,’ explains Amanda Cordell, CEO of the<br />

EOS Network.<br />

‘Therefore, it is extremely important that we<br />

improve the awareness of this condition<br />

amongst not just the public, but healthcare<br />

professionals too.’<br />

‘EoE has a considerable impact on the quality<br />

of life and the self-esteem of patients,’ explains<br />

Professor Stephen Attwood, Consultant<br />

Surgeon and Honorary Professor at Durham<br />

University, and one of the first doctors to<br />

identify and highlight the condition. ‘Not only<br />

do many develop adaptive eating strategies<br />

such as prolonged chewing, drinking copious<br />

amounts of liquids and avoiding certain foods,<br />

they also dread social situations and even<br />

eating with the families. Adults can be labelled<br />

as having psychological eating disorders whilst<br />

young children often fail to thrive and can suffer<br />

from malnutrition.<br />

‘Therefore, it is vital that there is greater<br />

general and clinical awareness of the<br />

condition. A key message for clinicians<br />

has to be that any patient who presents<br />

with pain on eating or feeling that food is<br />

sticking in the throat – especially if they<br />

have a history of allergic illnesses such as<br />

rhinitis asthma and eczema – should be<br />

referred for biopsies with a specific request<br />

to look for eosinophils. On diagnosis the<br />

gastroenterologist and patient should<br />

discuss the treatment options. These may<br />

include dietary exclusions - although these<br />

can often be difficult to maintain - PPIs<br />

that are effective for some patients or a<br />

topical steroid delivered directly to the site<br />

of inflammation that has been shown to<br />

maintain clinical and pathologic remission<br />

for 48 weeks in many patients. All patients<br />

need follow up and a long term care plan to<br />

manage this chronic disease.’<br />

Amanda Cordell comments ‘Our aim is to<br />

ensure that patients are empowered with<br />

information to take to their clinicians and that<br />

clinicians in all specialities are aware of EoE<br />

so that they recognise the symptoms reported<br />

by their patients, Think EoE and provide the<br />

appropriate care. This will be further supported<br />

by the first British medical diagnosis and<br />

treatment guidelines which we expect to see<br />

published later this year.<br />

‘EoE is a very unpleasant and life-changing<br />

condition, but conversely it is relatively easy to<br />

recognise, diagnose and treat,’ ‘We hope our<br />

campaign will remind everyone to ‘Think EoE’<br />

and help to make this happen.’<br />


GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

<strong>Gastroenterology</strong> <strong>Today</strong> welcomes the submission of<br />

clinical papers and case reports or news that<br />

you feel will be of interest to your colleagues.<br />

Material submitted will be seen by those working within all<br />

UK gastroenterology departments and endoscopy units.<br />

All submissions should be forwarded to info@mediapublishingcompany.com<br />

If you have any queries please contact the publisher Terry Gardner via:<br />

info@mediapublishingcompany.com<br />


NEWS<br />

Eosinophilic Awareness Week 16 – 22nd May<br />

launched the ‘Think EoE’ campaign. EOS<br />

Network activities include the development<br />

of a patient information pack including a food<br />

obstruction patient action plan and symptom<br />

tracker, and emergency care education<br />

through an A&E awareness poster. Additionally,<br />

members of the EoE community will be visiting<br />

local GPs to provide information leaflets and<br />

posters to help with wider understanding of the<br />

disease and recognition of the symptoms.<br />

Find out more at www.eosnetwork.org<br />

For EoE case studies, or to interview Amanda<br />

Cordell, please contact Isla Whitcroft at Healthy<br />

PR on 07768661189 or email Islawhitcroft@<br />

healthypr.co.uk<br />

About the EOS Network Charity<br />

The EOS Network’s mission is to ensure<br />

that every person with an Eosinophilic<br />

Gastrointestinal Disease receives a prompt<br />

accurate diagnosis, the right treatment for<br />

them and support to live with their condition.<br />

Its vision is for a world where everyone with an<br />

Eosinophilic Gastrointestinal Disease can eat<br />

without pain.<br />

The EOS Network provides information and<br />

support for patients and their families, a<br />

global platform for clinicians and researchers,<br />

educational resources and events and works<br />

with medical bodies, manufacturers and<br />

funders to ensure that the patient’s voice is<br />

heard.<br />

Brief notes on EOE (for more detail see<br />

media pack)<br />

EoE is clinically characterized by oesophageal<br />

dysfunction and histologically characterized by<br />

an eosinophil-rich inflammation, most probably<br />

caused by common food allergies or other<br />

environmental triggers. Often misdiagnosed as<br />

GORD, 4 adult symptoms include dysphagia,<br />

bolus obstruction and chest pain related<br />

to swallowing, heartburn and regurgitation.<br />

In children they can include reflux-related<br />

symptoms, nausea, vomiting, abdominal pain,<br />

refusal to eat or failure to grow. 2 Untreated<br />

EoE can lead to oesophageal remodelling<br />

including the formation of strictures. EoE<br />

is the cause of more than 50% of all<br />

emergency presentations for oesophageal<br />

food bolus impactions. 1<br />

Annual incidence rates of EoE in western<br />

countries are 7 cases per 100,000 with<br />

prevalence rates of 34 per 100,000. 2 However<br />

for patients with dysphagia and bolus<br />

50%. 5 Many patients have a history of atopy,<br />

particularly asthma, allergic rhinitis and eczema. 6<br />

EoE only received classification in the 1990s<br />

and disease awareness, amongst both<br />

clinicians and the general public, is thought to<br />

be low. Currently, average time to diagnosis<br />

is up to 8.1 years. 2 Due to the patchy nature<br />

of the disease, diagnosis requires six biopsies<br />

to be taken from around the oesophagus via<br />

endoscopy. Diagnosis is defined by histological<br />

presence of eosinophils ≥15hpf.<br />

Treatment for EoE is focused around three<br />

areas: dietary exclusion, drugs and dilatation.<br />

Dietary exclusion is generally considered<br />

hard to maintain and costly. Dilatation,<br />

carried out when the disease has progressed<br />

to oesophageal strictures, is an invasive<br />

procedure which manages the symptoms<br />

but not the cause of EoE and often has to be<br />

repeated.<br />

Until recently, all drug treatments were off-label<br />

and topical steroid therapy was not optimised<br />

for delivery to the oesophagus. However<br />

after approval from the EMA, NICE and the<br />

SMC have now recommended budesonide<br />

orodispersible tablet (Jorveza ® ) for active EoE<br />

in adults, a treatment option designed to reach<br />

the area of inflammation in the oesophagus<br />

Current clinical guidelines can be found @<br />

obstruction, prevalence can be between 23-<br />

https://www.eosnetwork.org/medicalguidelines<br />

References<br />

1. Gastrointest Pharmacol Ther 2016; 7(2):<br />

207-13. Ahmed M. World J<br />

2. Orodispersible budesonide tablets for the<br />

treatment of eosinophilic esophagitis: a<br />

review of the latest evidence. Ther Adv<br />

Gastroenterol 2020, Vol. 13: 1–15. Miehlke<br />

S, Lucendo AJ, Straumann A, Bredenoord<br />

AJ and Attwood S<br />

3. Gastrointest Pharmacol Ther 2016; 7(2):<br />

207-13. Ahmed M. World J<br />

4. Eosinophilic esophagitis N Engl J Med.<br />

2015;373(17):1640–8. Furuta GT, Katzka<br />

DA.<br />

5. Prevalence of eosinophilic oesophagitis in<br />

adults presenting with oesophageal food<br />

bolus obstruction. World J Gastrointest<br />

Pharmacol Ther 2015;6:244–247. Heerasing<br />

N, Lee SY, Alexander S, et al<br />

6. Aliment Pharmacol Ther 2016; 43(1): 3-15.<br />

Arias Á et al<br />

Amanda Cordell Interview<br />

As awareness of the upper GI condition<br />

Eosinophilic Oesophagitis grows, including<br />

its significant impact on the quality of life<br />

for those affected, we talk to Amanda<br />

Cordell, Chair and Founder of the charity<br />

The EOS Network, to discover the inspiring<br />

story behind the founding of the charity<br />

which supports both patients and clinicians<br />

working in this field.<br />

When Amanda Cordell’s seven month old baby<br />

Samuel was diagnosed with multiple protein<br />

allergies and eosinophilic gastrointestinal<br />

disease back in 2003, she naturally searched<br />

around for any information which would help<br />

her to support her son.<br />

‘It quickly became clear that there was absolutely<br />

nothing out there,’ says Amanda. ‘My husband<br />

and I felt completely helpless and very isolated.’<br />

<strong>Today</strong>, Amanda is chair of the The EOS<br />

Network, which grew out of a Yahoo support<br />

group that she formed in 2005. The Network<br />

has a strong community of parents, carers<br />

and adult patients and over 2,000 followers on<br />

social media. The Network provides them with<br />

somewhere to turn for support, advice and gold<br />

standard information on eosinophilic diseases<br />

which run throughout the gut. Eosinophilic<br />

Oesophagitis (EoE) is the most common<br />

disorder, and a significant cause of oesophageal<br />

dysphagia and food bolus, whilst Eosinophilic<br />

Gastroenteritis (EGE), Gastritis (EG), and Colitis<br />

(EC), all appear in the middle and lower gut.<br />

In addition, over 100 clinical professionals from<br />

13 countries have already signed up to the<br />

charity’s Professional Network, all benefitting<br />

from rapid access to the latest clinical<br />

research, guidelines, medical education,<br />

patient resources as well as global networking<br />

and discussion opportunities. There are also<br />

collaborative partnerships with medical bodies<br />

‘Our professional network provides a platform<br />

to connect, collaborate and innovate in all<br />

things Eosinophilic,’ says Amanda. ‘In addition,<br />

the ripple effect means that our members can<br />

educate their colleagues about the condition<br />

which is, of course vital, if more patients are to<br />

be helped.<br />

‘As a patient advocate and as the parent of<br />

two children living with eosinophilic diseases,<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />


NEWS<br />

I understand that it can feel like a pretty<br />

hopeless situation. Having an HCP in your<br />

corner who is supportive and knowledgeable<br />

makes such a huge difference.”<br />

When Amanda Cordell’s son Samuel was born<br />

17 years ago, he slept peacefully through the<br />

first night of his life. It was the last time he was<br />

to enjoy that simple luxury.<br />

‘The signs that something was wrong with<br />

Samuel were there from the first few days of<br />

his life, says Amanda. ‘He always seemed<br />

uncomfortable and never settled at night.<br />

He was a fussy eater who vomited up my<br />

breast milk, he developed cradle cap and then<br />

eczema which become infected so badly that<br />

he had to be admitted to our local hospital.’<br />

In hospital Samuel caught Rotavirus and was<br />

placed on a special feed but even when he<br />

was well enough to be discharged, he still<br />

suffered constant vomiting, whilst his explosive<br />

bowel movements overflowed his nappy.<br />

‘We hardly slept for months,’ remembers<br />

Amanda. ‘We would take it in turns to walk<br />

up and down with him all night whilst he cried<br />

or was sick. We were new parents, so it was<br />

sometimes hard to know what was normal<br />

and our GP and the local hospital seemed to<br />

have little idea on how to help us. David and<br />

I were convinced however, that there was a<br />

connection between his bowel issues, eczema<br />

and vomiting.’<br />

where people understood what you were going<br />

through but also where there was hope for the<br />

future. I came back to the UK and started up<br />

an online UK support group and things just<br />

went from there.’<br />

‘We quickly discovered that there was a<br />

whole raft of people, often with very poorly<br />

children who were simply desperate for help.<br />

On the clinical side there was clearly a huge<br />

knowledge gap and a lack of consensus on<br />

how to treat these patients.<br />

Their daughter Heather born in 2007 was also to<br />

develop gut problems, eczema and immediate<br />

allergies. “It was devasting to hear our daughter<br />

also be given an eosinophilic diagnosis.”<br />

We spent the next few years raising funds and<br />

with the support of other families affected by<br />

eosinophilic diseases in 2010, we registered<br />

our group as a charity.<br />

‘Sadly, in December 2013, Samuel became<br />

seriously ill and I was forced to a back seat for<br />

a few years, but in the meantime the need for<br />

research, diagnosis consensus and treatments<br />

became even greater.”<br />

‘I went back to Cincinnati for the 2017 CURED<br />

conference and was completely humbled<br />

by the great work that the researchers<br />

and patient advocates had done in driving<br />

forward awareness and change in the USA.<br />

The meeting had attendees and presenters<br />

from around the globe, including the UK’s<br />

Professor Stephen Attwood who first identified<br />

eosinophilic oesophagitis. I came back inspired<br />

with the aim of bringing together the global<br />

expertise to improve disease awareness,<br />

access to medical care and patient support for<br />

all those suffering with eosinophilic diseases.’<br />

The charity was relaunched in 2019 as<br />

the EOS Network, now supported by a<br />

medical and scientific board. The change<br />

in constitution provided two arms, one a<br />

community hub for patients and their families<br />

and the other a global network for HCPs.<br />

‘There is a real need to expand our reach,<br />

to more patients their families and HCPs, ‘<br />

says Amanda. ‘Both here and abroad it is still<br />

difficult for people to get in front of an HCP who<br />

understands EOS diseases which can mean a<br />

delay in diagnosis and access treatments. The<br />

last 8 months have been a huge success but<br />

there is still a lot of work to be done.”<br />

If you need more information or you would like<br />

to get involved go to www.eosnetwork.org or<br />

email contactus@eosnetwork.org<br />

At seven months, Samuel was referred to a<br />

paediatric gastroenterologist who diagnosed<br />

him with eosinophilic gastrointestinal disease<br />

as the cause of his relentless symptoms.<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

‘We didn’t know it then, but we were at the start<br />

of a very long, tough journey,’ says Amanda.<br />

Samuel was placed on a highly restrictive<br />

diet with elemental feed and Amanda started<br />

to search for information that might help her<br />

and David to support their son. Whilst there<br />

was virtually no information on the condition<br />

in the UK and Europe, Amanda learned about<br />

the work being carried out into gut allergies<br />

and eosinophilic disorders at the Cincinnati<br />

Children’s Hospital. In 2005 she and her<br />

husband David attended a conference when,<br />

for the first time, they realised the value of<br />

having a support group.<br />

‘It was such as relief to be in an environment<br />


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GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />


REPORT<br />




May, <strong>2022</strong> – Opioids are widely used to treat serious pain,<br />

including in patients with cancer. The majority of these<br />

patients will experience the side-effect of opioid-induced<br />

constipation (OIC), caused by the opioids binding to the<br />

μ-receptors in the enteric system.<br />

aware of the importance of diagnosing OIC, monitoring the condition<br />

and providing appropriate treatment. For example, peripheral-acting mu<br />

opioid receptor antagonists (PAMORAs) are a unique class of drugs that<br />

act directly on the mechanism causing OIC, and are therefore far more<br />

effective than traditional treatments.<br />

There has been a sharp increase in the prescribing of opioids to patients<br />

with chronic pain. However, despite the debilitating side effect of<br />

constipation many healthcare professionals continue to prescribe opioids.<br />

Recommendations<br />

The Cost of Opioid-induced Constipation report recommends that<br />

clinicians:<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

28<br />

OIC has a devastating effect on people’s lives but is often treated with<br />

laxatives, which have limited effect. OIC frequently has a negative impact<br />

on patients’ quality of life, including their ability to perform daily activities<br />

and work productively, yet there is little recognition of the condition and<br />

how to manage it.<br />

The Bowel Interest Group’s latest report, The Cost of Opioid-induced<br />

Constipation, will be published in June and sets out to educate primary<br />

and secondary healthcare professionals in the management of OIC.<br />

Key facts<br />

• Studies suggest that OIC affects between 41% and 57% of patients<br />

taking opioids for pain and 87% of patients with terminal cancer using<br />

opioids. 1<br />

• Doctors are prescribing laxatives for OIC, even though their<br />

effectiveness is limited.<br />

• Constipation is one of the most common reasons patients avoid<br />

taking opioid treatments or stop taking them.<br />

• There appears to be a clear relationship between higher levels of<br />

opioid analgesic prescribing and laxative prescribing rates. 2<br />

• There is a close correlation between opioid prescribing rates and<br />

admissions to hospital for constipation. 3<br />

• In 2018-19, the estimated annual spend by NHS England on<br />

constipation was £168 million. 4<br />

• In 2021, nearly 23 million opioid analgesic prescriptions were<br />

dispensed in the community, at a cost of approximately £202 million. 2<br />

OIC is underdiagnosed and therefore undertreated 1 or sometimes<br />

inappropriately treated. Not all doctors adhere to the Rome IV criteria<br />

for diagnosing OIC. Conventional treatments such as dietary changes<br />

and laxatives are rarely effective in treating OIC, but doctors continue to<br />

prescribe them.<br />

OIC can be very psychologically distressing for patients, who may<br />

choose to manage the condition themselves. This can include reducing<br />

their dose of opioids or even stopping taking opioids altogether.<br />

Better education of health professionals is needed so that they are<br />

Refences<br />

1. Cobo Dols M., Beato Zambrano C., Cabezón-Gutiérrez L., et al. (2021). One-year efficacy and safety of naloxegol<br />

on symptoms and quality of life related to opioid-induced constipation in patients with cancer: KYONAL study.<br />

BMJ Supportive & Palliative Care.<br />

2. Prescription data for section code 040702 (Opioid Analgesic Prescribing), 0106 Laxative Prescribing), and<br />

010606 (PAMORA Prescribing) from Jan 2017 – Dec 2021. Accessed March <strong>2022</strong> from NHS BSA England<br />

Prescribing Database and Openprescribing.net.<br />

• take a more proactive approach in the management of OIC, using a<br />

standard, symptom-based definition of the condition<br />

• educate themselves about treatment options<br />

• ask the patient regularly about symptoms<br />

• ensure that patients receive therapy that manages their pain<br />

appropriately while avoiding the debilitating consequences of OIC.<br />

Professor Anton Emmanuel, Professor in Neuro-<strong>Gastroenterology</strong><br />

at University College London and Consultant Gastroenterologist at<br />

University College Hospital and the National Hospital for Neurology and<br />

Neurosurgery (Queen Square), says:<br />

“The Cost of Opioid-Induced Constipation Report emphasises the<br />

devastating impact that OIC has on patients, who face a stark choice of<br />

whether to endure the impact of chronic pain, or the pain of the constipation<br />

that results from taking the very painkillers that should be helping them.<br />

Patients' quality of life is severely impacted by the condition – what they are<br />

experiencing is often very distressing, not just a ‘nuisance’. Studies suggest<br />

that OIC affects between 41% and 57% of patients taking opioids for pain,<br />

and up to 87% of patients with terminal cancer using opioids.<br />

“OIC is often misdiagnosed and therefore sometimes inappropriately<br />

treated. Usual constipation treatments such as diet changes of<br />

prescribing of laxatives rarely work in treating OIC, because they do<br />

not target the underlying cause; the opioid binding to the μ-receptors.<br />

Inappropriate treatment leaves many patients to attempt to treat the<br />

condition themselves, while all the time enduring their chronic pain.<br />

More education for healthcare professionals in diagnosing, appropriately<br />

treating and managing OIC is needed. The Cost of Opioid-Induced<br />

Constipation Report highlights the urgency of the need and also the<br />

cost, both in terms of the financial cost to the NHS, and the cost of the<br />

impact on patients’ wellbeing and quality of life.”<br />

The full report will be available on the Bowel Interest Group’s website in<br />

June.<br />

For more information on the work of the Bowel Interest Group, visit<br />

www.bowelinterestgroup.co.uk.<br />

3. Admissions data for ICD 10 diagnosis code K59.0 (Constipation) from April 2016 to January 2020. Accessed May<br />

2020 from Vantage System provided by Health IQ.<br />

4. Bowel Interest Group (2020). Cost of constipation report. 2020. Available from: https://bowelinterestgroup.co.uk/<br />

wpcontent/uploads/2020/07/Cost-of-Constipation-2020.pdf<br />

5. Kumar, L., Barker, C., Emmanuel, A. (2014). Opioid-Induced Constipation: Pathophysiology, Clinical<br />

Consequences, and Management, <strong>Gastroenterology</strong> Research and Practice. 2014. https://doi.<br />






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atrophic gastritis (AG) and Helicobacter pylori (Hp) infection<br />

in patients referred for gastroscopy. 1 This unique blood test is<br />

designed for the first-line diagnosis of Hp infection and AG in<br />

patients with upper abdominal symptoms, such as dyspepsia<br />

and gastro-oesophageal reflux disease (GORD), before<br />

endoscopy. GastroPanel is also the only test on the market<br />

capable of monitoring the regulatory mechanism of acid<br />

output in the stomach.<br />

Hp infection, AG and high acid output are important risk factors<br />

for gastric and oesophageal cancers. The new generation (unified)<br />

GastroPanel test works on the same principle as the original<br />

GastroPanel ELISA test and is designed to harmonize the ELISA<br />

processing conditions of four biomarkers. This highly informative assay<br />

is therefore a cost-effective solution for population-based screening for<br />

the risk of gastric cancer in asymptomatic and symptomatic individuals,<br />

and its efficacy has already been confirmed by several studies in both<br />

high- and low-risk countries.<br />

This latest study evaluated the diagnostic accuracy of the new<br />

generation GastroPanel test for the diagnosis of both AG and Hp<br />

infection in patients referred for gastroscopy from Primary Care with<br />

different indications. Along with the previously published clinical<br />

validation studies, 2,3 this biopsy-confirmed study was designed to<br />

verify the diagnostic capabilities of the new generation GastroPanel<br />

test compared to the current gold standard (gastroscopy and biopsy<br />

analysis), and to demonstrate its performance was comparable to the<br />

original GastroPanel test. The positive results from this study also pave<br />

the way for BIOHIT’s new GastroPanel Quick Test (point of care test)<br />

which will be launched in Q1 <strong>2022</strong>.<br />

Dr. Olli-Pekka Koivurova, Principal Investigator of the study at OUH,<br />

commented: “A total of 522 patients referred for gastroscopy at the<br />

Gastro Centre, OUH, were consented and enrolled for this particular<br />

study. Blood was sampled for all patients using the GastroPanel test,<br />

along with performing quality-controlled gastroscopies with mucosal<br />

biopsies. The results confirmed that the new generation GastroPanel<br />

is a highly accurate test for the non-invasive diagnosis of AG and Hp<br />

infection in patients referred for diagnostic gastroscopies.”<br />

For more information visit www.biohithealthcare.co.uk/gastropanel.<br />

1. Koivurova O-P, et al. Serological biomarker panel in diagnosis of<br />

atrophic gastritis and Helicobacter pylori infection in gastroscopy<br />

referral patients. Clinical validation of the new generation GastroPanel ®<br />

test. Anticancer Res. 2021, 41, 5527-5537.<br />

2. Koivurova O-P, et al. Screening of the patients with autoimmune<br />

thyroid disease (AITD) and type 1 diabetes mellitus (DM1) for atrophic<br />

gastritis (AG) by serological biomarker testing (GastroPanel ® ). EC<br />

Gastroenterol. Digest. Syst, 2020, 7, 181-195.<br />

3. Mäki M, et al. Helicobacter pylori (Hp) IgG ELISA of the newgeneration<br />

GastroPanel ® is highly accurate in diagnosis of Hp-<br />

Infection in gastroscopy referral patients. Anticancer Res, 2020, 40,<br />

6387-6398.<br />

About BIOHIT Healthcare Ltd<br />

BIOHIT Healthcare Ltd (www.biohithealthcare.co.uk) is part of<br />

the Finnish public company, BIOHIT OYJ, which specialises in the<br />

development, manufacture and marketing of products and analysis<br />

systems for the early diagnosis and prevention of gastrointestinal<br />

diseases. The company’s many unique and patented diagnostic tests<br />

transform clinical practice and make screening, diagnosis and monitoring<br />

of gastrointestinal diseases efficient and cost effective. Non-invasive<br />

diagnostics are at the core of BIOHIT’s offering, making it the provider of<br />

choice for leading gastroenterologists and laboratory scientists worldwide.<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />




Symprove is a patented water-based probiotic that delivers viable<br />

bacteria to the gastrointestinal tract, as evidenced by extensive<br />

in-vitro data utilising the Simulator of the Human Intestinal<br />

Microbial Ecosystem (SHIME ® ). 1-3 Independent research to date<br />

has been undertaken in collaboration with research partners<br />

including University College London and King’s College London.<br />

With existing randomised controlled trials including irritable<br />

bowel syndrome, inflammatory bowel disease and diverticular<br />

disease completed, 4-6 further studies underway with key<br />

research partners including Sheffield Hallam University, include<br />

diverticulitis and Parkinson’s disease. These studies are due for<br />

publication in <strong>2022</strong>-2023. A full summary of Symprove published<br />

data is available at symproveforprofessionals.com.<br />

Dr Andrew Thillainayagam, consultant gastroenterologist, Imperial College<br />

Healthcare NHS Trust, London: “Behavioural disorders of the gut, what we<br />

call functional bowel disorders, of which IBS is one, have a terrible impact on<br />

people’s quality of life. I recommend Symprove to almost all of my patients<br />

who have functional problems in the gut, based on the enormous amount of<br />

clinical evidence behind it, which includes randomised controlled trials.”<br />

London: “Symprove is different<br />

from other probiotics because<br />

it is water-based, which means<br />

it limits exposure to gastric<br />

juices and digestive enzymes in<br />

the stomach. Symprove is also<br />

fermented, enabling the bacteria<br />

to grow and become used to<br />

an acidic environment as part of<br />

the manufacturing process. This<br />

means when a patient swallows<br />

Symprove, the bacteria are able to<br />

survive the stomach acid and then<br />

thrive in the colon.”<br />

Barry Smith, Founder of Symprove Ltd, says: “At Symprove, we pride<br />

ourselves on our loyal customer base, with 92% of people feeling the<br />

difference at 12 weeks in their Symprove journey. We are hugely excited<br />

about what the future holds, as we expand our research programme to<br />

support different patient groups.”<br />

Prof Simon Gaisford, Professor of Pharmaceutics, University College<br />

Find out more at symproveforprofessionals.com<br />

Refences<br />

1. Fredua-Agymean M, et al. Benef Microbes 2015;6(1):141–51.<br />

2. Ghyselinck J, et al. Int J Pharm X 2021:3:100087.<br />

3. Ghyselinck J, et al. Int J Pharm 2020;587:119648.<br />

4. Sisson G, et al. Aliment Pharmacol Ther 2014;40(1):51–62.<br />

5. Bjarnason I, et al. Inflammopharmacology 2019;27(3):465–473.<br />

6. Kvasnovsky CL, et al. Inflammopharmcology 2017; doi: 10.1007/s10787-017-0363-y.<br />




GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

The BIOFIRE ® Blood Culture Identification 2 (BCID2) Panel<br />

rapidly detects pathogens and antimicrobial resistance genes,<br />

directly from positive blood cultures, to shorten the time to<br />

optimal therapy for sepsis. To monitor accuracy and precision<br />

of the whole system the new Streck MDx-Chex Control is<br />

the first-of-its-kind quality control, specifically designed to<br />

meet the standards for verifying the entire analytical process<br />

of the BioFire BCID2 sepsis assay. It provides confidence<br />

in instrument results to ensure the best patient treatment<br />

decisions.<br />

Now available in the UK from Alpha Laboratories, MDx-Chex<br />

evaluates the entire analytical process of the assay, including cell<br />

lysis, DNA extraction, purification and removal of PCR inhibitors, as<br />

well as qPCR amplification, detection and analysis.<br />

MDx-Chex contains 43 bacteria, yeasts and antimicrobial resistance<br />

gene targets covering all those tested on the BIOFIRE BCID2 Panel. The<br />

intact, inactivated microorganisms are suspended in a matrix of stabilized<br />

red and white blood cells, plus blood culture media components, designed<br />

to challenge the lysis and purification processes, just like a patient sample.<br />

Routine use of MDx-Chex for BCID2 as a full process quality control can help<br />

identify variations in the test system that can lead to incorrect results. It can be<br />

used as a 3rd party quality control to support ISO 15189 compliance.<br />

View the MDx-Chex for BCID2 Best Practice Guide at:<br />

https://www.youtube.com/watch?v=1z0g5DVtCEU<br />

Please visit www.alphalabs.co.uk for further information or contact<br />

Alpha Laboratories on 0800 38 77 32 or email<br />

marketing@alphalabs.co.uk<br />



Thousands of<br />

healthcare professionals<br />

recommend Symprove<br />

Symprove is a live liquid-based probiotic<br />

containing four strains of bacteria*<br />

Evidence-based: Independent research conducted at<br />

University College London and King’s College London.<br />

Safety: Well tolerated, long history of safe use.<br />

All strains are fully characterised.<br />

Here are the reasons why:<br />

Survival: In vitro/in vivo research demonstrating<br />

viability of bacteria through the gut.<br />

Formulation: Manufactured to ensure<br />

bacterial tolerance through the gut.<br />

For more information please visit: symproveforprofessionals.com<br />

GASTROENTEROLOGY TODAY - SUMMER <strong>2022</strong><br />

*Lacticaseibacillus rhamnosus NCIMB 30174, Enterococcus faecium NCIMB 30176, Lactobacillus acidophilus NCIMB 30175, Lactiplantibacillus plantarum NCIMB 30173.<br />


Helicobacter Test INFAI ®<br />

The most used 13 C-urea breath test for the<br />

diagnosis of Hp-infection worldwide<br />

• more than 4.5 million INFAI tests performed in Europe<br />

• approved for children from the ages of 3 to 11<br />

• special INFAI test for patients with dyspepsia taking PPIs<br />

• cost-effective CliniPac Basic version for hospital use<br />

INFAI Institute for Biomedical Analysis & NMR Imaging, INFAI UK Ltd<br />

Innovation Centre, University Science Park, University Road, Heslington, YORK YO10 5DG, UK<br />

Phone +44 1904 435 228 - Fax +44 1904 435 229 - mail: info@infai.co.uk - Visit us at www.infai.com

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